Nokea
The nurse is caring for a client three hours postpartum after delivering a term newborn infant. Which assessment finding would indicate an early sign of postpartum hemorrhage?
- A. Heart rate change from 80 to 125 bpm
- B. Blood pressure change from 125/90 to 119/82 mmHg
- C. A decrease in respiratory rate from 22 to 16 breaths per minute
- D. Saturation of one peri-pad since delivery
Correct Answer: A
Rationale: Tachycardia (heart rate increase to 125 bpm) is an early sign of postpartum hemorrhage due to compensatory response to blood loss.
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The following scenario applies to the next 1 items
The emergency department nurse is caring for a 22-year-old with altered mental status
Item 1 of 1
Admission Notes
2330 – 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Vital Signs
• Temperature 98.0o F (37o C)
• Pulse 110/minute
• Respirations 16/minute
• Blood Pressure 155/96 mm Hg
• O2 saturation 96% on room air
Complete the following sentences from the list of options.. Based on the client assessment, the client is likely intoxicated with ___ the nurse should immediately ___ based on the client's ___
- A. heroin
- B. cocaine
- C. restrain the client
- D. obtain a urine drug screen
- E. blood pressure
- F. physical violence
Correct Answer: B, C, F
Rationale: The client's agitation, hyper-alertness, and violence suggest cocaine intoxication. Immediate restraint ensures safety, and violence justifies this action.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as
- A. obsessive desire for the euphoric effects of a drug
- B. a need for a drug to avoid physical withdrawal symptoms
- C. severe effects that may be life-threatening
- D. unpleasant symptoms related to the absence of a drug
Correct Answer: B
Rationale: Physical dependence is defined as needing a drug to avoid withdrawal symptoms.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 6 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse transfused the prescribed fresh frozen plasma. Click to specify which assessment data is necessary after the transfusion of FFP.
- A. international normalized ratio
- B. activated thromboplastin time (aPTT)
- C. hematocrit
- D. vital signs
Correct Answer: A, D
Rationale: INR and vital signs are critical to assess the effectiveness of FFP in correcting coagulopathy and monitoring for transfusion reactions.